FORMULIR PENGADUAN PELANGGAN/COMPLIANCE FORM
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Tanggal Lapor/ date report *
MM
/
DD
/
YYYY
Jam/ Time *
Time
:
Petugas yang menerima keluhan/ PIC
Unit Kerja/ unit *
Lainya.....
1. Pelanggan/ Complainer
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2. Penyampaian Keluhan/ complain delivery *
Identitas Pelapor/ Complainer identity
Nama/Name *
Kewarganegaraan/ Nationality *
Alamat/addres
Telepon/ phone
Keluhan Pasien/ Complainer *
Tindak Lanjut Petugas/ Follow Up Officers *
Submit
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